Psychological interventions

Common psychotherapeutic activities performed by the psychiatrist faced with medically ill patients include helping patients to endure or overcome pain, fear, and denial, to grieve after loss or to face dying and death, to adapt to the sick role; to effect changes in self, object, and ideal self representation, and to enhance their capacity to endure dependency, isolation, sleep disturbance, etc. The psychiatrist can also help patients' families to cope with the disruption caused by illness and the caretaking staff to recognize and integrate psychosocial factors in care plans. Interventions should be geared to the needs of the patient, the family and the medical team and take into account the personal abilities of the psychiatrist. Any kind of orthodoxy is inappropriate.

Grawe's model of research-informed psychotherapy may help to decide on the most appropriate focus of and approach to treatment in a given case.(5) He differentiates four empirically validated mechanisms of change based on four principal perspectives:

• mastery/coping from a competence perspective

• clarification of meaning from a motivational perspective

• problem actuation from a problem perspective

• resource activation from a resource perspective.

Each of these can focus on both the intrapersonal-intrapsychic and the interpersonal-relational domains. In Grawe's view, traditional psychotherapy 'schools' (behavioural, psychodynamic, etc.) have restricted themselves to predominantly one or two perspectives at the expense of the patient who is confronted with issues in all domains.

Mastery/coping refers to the patient's real-life mastery experiences, i.e. the concrete experience of learning to cope with situations experienced in the past as very difficult or anxiety provoking. When the therapist approaches the patient's problems according to the principle of mastery, he or she views them in terms of being able versus not being able to do something. The therapist views the patient's state as concrete instances of not being able to do otherwise, without giving the matter any deeper consideration. If therapists are to help their patients, they need a detailed disorder-specific understanding of the specific determinants of their patients' problems and the skills to make an appropriate translation of this understanding into practice. This principle of change is emphasized in cognitive-behavioural approaches.

Clarification of meaning refers to the uncovering and identification of guiding motivations, and appraisal of a situation in the light of such motivations. More often than not these motivations and appraisals are unconscious or not readily available. The threatening meaning of a particular situation or event with respect to specific goals is clarified, or the importance of these goals is revised by making explicit the implicit meanings involved. This may sometimes lead to a dramatic change in the appraisal of the situation and the patient's feelings. This principle of change is emphasized in psychodynamic approaches.

Problem actuation refers to the view that problems can most effectively be changed while the person experiences them. Techniques to make the problem experientially available include the use of the transference relationship in psychodynamic therapies, seeking out real situations in behaviour therapy, and inclusion of real interactional partners in couple, family, and group therapies.

Resource activation refers to the necessity to tap the patient's motivational readiness and abilities which, if skilfully activated and effectively used, are at the core of effective therapy. Therapists need to adapt the help offered so that patients can experience their own strengths and positive aspects. Most important in this respect is how therapists approach the therapeutic relationship and, more generally, how effective they are in inviting patients into the therapeutic endeavour. A large amount of flexibility and variability of the therapeutic repertoire is necessary in resource-oriented therapy.

Combined treatments

As in other aspects of psychiatry, pharmacological and psychosocial treaments are complementary. Case management

Case management is intended to improve the co-ordination of care provided by the various services involved. Originally used in psychiatry, it is also useful in the psychiatric treatment of the medically ill. Different types of case management have four elements in common: patients' needs are assessed, a plan is made to provide services which meet these needs, the services are provided, and the patient and the services are monitored. In patients with comorbid psychiatric and medical illness, the most crucial task is to determine who oversees the complete integrated treatment effort. Several solutions are possible. The classical consultation approach assumes that the physician or surgeon is the clinical manager responsible for integration. Liaison approaches allow a more active role for the psychiatrist, who may be in charge of co-ordinating the different psychosocial approaches to treatment and who, jointly with the physician or surgeon, attempts to integrate biomedical and psychosocial treatments. In medical-psychiatric or psychosomatic units the management function is usually the responsibility of the chief of service. Even though they are clinically relevant, the benefits of case-management approaches in medical settings seem not to have been evaluated in controlled studies.

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